Information and Referral Request Form
This is an information and referral request—not an application. YCAN serve's people who live in Park, Hot Springs, or live or work inTeton County, Wyoming. Outside these areas, please contact Wyoming 211. We are a small team and cannot respond outside our service area.
Please provide your contact and household information so we can review your request.
Are you seeking information for yourself or someone else?
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Myself
Someone else
Do you need non-emergency financial assistance in Park, Hot Springs, or Teton County?
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Yes
No
Have we helped you before?
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Yes
No
Name
*
Date of Birth (if we helped you before this helps us find your information)
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
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13
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30
31
Day
Please select a year
0
01
011
0111
01111
Year
Email
*
example@example.com
Phone Number/Message Number
*
-
Address of the Person Seeking Information
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What county does the person seeking information live in?
*
Please Select
Park County Wyoming
Hot Springs County Wyoming
Teton County Wyoming
Work in Teton County, Wyoming
Other county outside service area
Do you work with any local service provider?
*
Yes
No
Who do you work with?
Household income for the last 30 days
*
Household/Family Size
*
Gross household income amount approx before deduction for the last 30 days
*
CSBG Income Eligibility Quick Check
Do you consent to release your information for referral to the appropriate agency in your county?
*
Yes
No
Your Message to YCAN
*
Back
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Please verify that you are human
*
Send
Should be Empty: